- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,677.35 / $11,481.54
| Facility | | $1,584.89 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $4,073.80
| Professional | | $1,445.44 | $1,737.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $13,489.63 / $28,183.83
| Facility | | $4,677.35 | $13,489.63 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,137.96 / $4,168.69
| Professional | | $1,412.54 | $2,137.96 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,677.35 / $13,182.57
| Facility | | $323.59 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,511.89 / $5,495.41
| Professional | | $1,584.89 | $2,511.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $3,890.45
| Professional | | $1,445.44 | $2,089.30 | $3,890.45 |